OBJECTIVE: In 2019, Quebec changed its stillbirth definition to include fetal deaths at 20 weeks gestation or more. Previously, the criterion was a minimum birth weight of 500 g. We assessed the impact of the new definition on stillbirth rates.
METHODS: We conducted a retrospective study of stillbirth rates between 2010 and 2021 in Quebec. The exposure consisted of the period during the new definition versus the preceding period. We assessed how the new definition affected stillbirth rates using interrupted time series regression, and compared the period during the new definition with the preceding period using prevalence differences and prevalence ratios with 95% confidence intervals (CI). We determined the extent to which fetuses at the limit of viability (under 500 g or 20‒23 weeks) accounted for any increase in rates.
RESULTS: Stillbirth rates went from 4.11 before the new definition to 6.76 per 1000 total births immediately after. Overall, the change in definition led to an absolute increase of 2.58 stillbirths per 1000 total births, for a prevalence ratio of 1.76 (95% CI 1.61‒1.92) compared with the preceding period. Fetal deaths due to congenital anomalies increased by 6.82 per 10,000 (95% CI 4.85‒8.78), while deaths due to pregnancy termination increased by 10.47 per 10,000 (95% CI 8.04‒12.89). Once the definition changed, 37% of stillbirths were under 500 g and 42% were between 20 and 23 weeks, with around half of these caused by congenital anomalies and terminations.
CONCLUSIONS: Stillbirth rates increased after the definition changed in Quebec, mainly due to congenital anomalies and pregnancy terminations.
RéSUMé: OBJECTIFS: En 2019, le Québec a modifié sa définition de mortinaissance pour inclure les morts fœtales à 20 semaines de gestation ou plus. Auparavant, le critère était un poids minimum de 500 g à la naissance. Nous avons évalué l’impact du changement de définition sur la mesure de mortinatalité. MéTHODES: Nous avons mené une étude rétrospective de la mortinatalité entre 2010 et 2021 au Québec. L’exposition était la période après l’introduction de la nouvelle définition par rapport à la période précédente. Nous avons évalué l’impact du changement de définition sur la prévalence de la mortinatalité en utilisant des régressions de séries temporelles interrompues, et en comparant la période suivant le changement de définition avec la période précédente à l’aide de différences de prévalences et de ratios de prévalences avec des intervalles de confiance à 95% (IC). Nous avons déterminé dans quelle mesure les fœtus à la limite de la viabilité (moins de 500 g ou 20 à 23 semaines) contribuaient à l’augmentation. RéSULTATS: La prévalence de la mortinatalité est passé de 4,11 avant la nouvelle définition à 6,76 pour 1 000 naissances immédiatement après le changement de définition. Il y a eu une augmentation absolue de 2,58 mortinaissances pour 1 000 naissances, pour un ratio de prévalences de 1,76 (IC à 95% 1,61‒1,92) comparativement à la période précédente. Les mortinaissances dues aux anomalies congénitales ont augmenté de 6,82 pour 10 000 (IC 95% 4,85‒8,78), tandis que les décès dus aux interruptions de grossesse ont augmenté de 10,47 pour 10 000 (IC 95% 8,04‒12,89). Une fois la définition modifiée, 37 % des mortinaissances survenaient chez des fœtus pesant moins de 500 g et 42 % avaient lieu entre 20 et 23 semaines, la moitié d’entre elles étant dues à des anomalies congénitales et interruptions de grossesse. CONCLUSION: La prévalence de la mortinatalité a augmenté après le changement de définition au Québec, principalement en raison des décès causés par des anomalies congénitales et des interruptions de grossesse.

Group A-streptococcal (GAS) infection can lead to various clinical presentations and is fulminant when it reaches the deep tissues, leading to a high morbidity and mortality. The severity of postpartum GAS infections is widely known. In this case report we describe the course of disease in a pregnant patient with GAS toxic shock syndrome with initial complaints of abdominal pain, diarrhea and fetal demise at first presentation. Within 10 hours this patient died. It is important to stay vigilant for a fulminant GAS infection in pregnant patients, to recognize it quickly and treat it adequately.

BACKGROUND: Intrauterine fetal death and perinatal death represent one of the most relevant medical scientific problems since, in many cases, even after extensive investigation, the causes remain unknown. The considerable increase in medical legal litigation in the obstetrical field that has witnessed in recent years, especially in cases of stillborn births, has simultaneously involved the figure of the forensic pathologist in scientific research aimed at clarifying the pathophysiological processes underlying stillbirth.
METHODS: our study aims to analyze cases of sudden intrauterine unexplained death syndrome (SIUD) to evaluate the role of oxidative stress in the complex pathogenetic process of stillbirth. In particular, the immunohistochemical expression of specific oxidative stress markers (NOX2, NT, iNOS, 8-HODG, IL-6) was evaluated in tissue samples of placentas of SIUDs belonging to the extensive case series (20 cases), collected from autopsy cases of the University of Ferrara and Politecnica delle Marche between 2017 and 2023.
RESULTS: The study demonstrated the involvement of oxidative stress in intrauterine fetal deaths in the placenta of the cases examined. In SIUD, the most expressed oxidative stress markers were NOX2 and 8-HODG.
CONCLUSIONS: The study contributes to investigating the role of oxidative stress in modulating different pathways in unexplained intrauterine fetal death (SIUD) tissues.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are peptide analogues that are used to treat type 2 diabetes mellitus (T2DM) and obesity. The first medication in this class, Exenatide, was approved in 2005, and these medications, specifically Semaglutide, have become more popular in recent years due to their pronounced effects on glycemic control, weight reduction, and cardiovascular health. Due to successful weight loss from these medications, many women previously diagnosed with oligomenorrhea and unable to conceive have experienced unplanned pregnancies while taking the medications. However, there is currently little data for clinicians to use in counseling patients in cases of accidental periconceptional exposure. In some studies examining small animals exposed to GLP-1RAs in pregnancy, there has been evidence of adverse outcomes in the offspring, including decreased fetal growth, skeletal and visceral anomalies, and embryonic death. Although there are no prospective studies in humans, case reports, cohort studies, and population-based studies have not shown a pattern of congenital anomalies in infants. A recent large, observational, population-based cohort study examined 938 pregnancies affected by T2DM and compared outcomes from periconceptional exposure to GLP-1RAs and insulin. The authors concluded there was not a significantly increased risk of major congenital malformations in patients taking GLP-1RAs, although there was no information on maternal glycemic control or diabetic fetopathy. As diabetic embryopathy is directly related to the degree of maternal hyperglycemia and not the diagnosis of diabetes itself, it is not possible to make this conclusion without this information. Furthermore, there is little evidence available regarding fetal growth restriction, embryonic or fetal death, or other potential complications. At this time, patients should be counseled there is not enough evidence to predict any adverse effects, or the lack thereof, of periconceptional exposure of GLP-1RAs during pregnancy. We recommend that all patients use contraception to prevent unintended pregnancy while taking GLP-1RAs.

Cases of mental illnesses and suicide attempts while pregnant are of grave concern because they negatively affect both the mother and her fetus. Here we report a case of an 18-year-old woman, who was found at 35 weeks into her pregnancy. She was unconscious when her sister-in-law rescued her. Upon arrival, she was agitated and had respiratory distress. She went into spontaneous labor the next day and delivered a premature infant who succumbed within 24 h. She had a history of mental illness in the past and previous suicide attempts. The reason for her suicide stemmed from conflicts within her family and disagreement with her husband. Various psychosocial elements play a role in suicide risk, such as young age, having a history of mental health issues, experiencing trauma facing domestic violence, and dealing with financial stress. This underlines the need for mental health screening in the course of antenatal visits for a complete risk assessment.

Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient\'s wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it\'s the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.

Despite efforts to reduce stillbirths and neonatal deaths, inconsistent definitions and reporting practices continue to hamper global progress. Existing data frequently being limited in terms of quality and comparability across countries. This paper addresses this critical issue by outlining the new International Classification of Disease (ICD-11) recommendations for standardized recording and reporting of perinatal deaths to improve data accuracy and international comparison. Key advancements in ICD-11 include using gestational age as the primary threshold to for reporting, clearer guidance on measurement and recording of gestational age, and reporting mortality rates by gestational age subgroups to enable country comparisons to include similar populations (e.g., all births from 154 days [22+0 weeks] or from 196 days [28+0 weeks]). Furthermore, the revised ICD-11 guidance provides further clarification around the exclusion of terminations of pregnancy (induced abortions) from perinatal mortality statistics. Implementing standardized recording and reporting methods laid out in ICD-11 will be crucial for accurate global data on stillbirths and perinatal deaths. Such high-quality data would both allow appropriate regional and international comparisons to be made and serve as a resource to improve clinical practice and epidemiological and health surveillance, enabling focusing of limited programmatic and research funds towards ending preventable deaths and improving outcomes for every woman and every baby, everywhere.

BACKGROUND: In post-mortem (PM) fetal and neonatal imaging, relevant clinical information is crucial for accurate interpretation and diagnosis; however, it is usually incomplete.
OBJECTIVE: To propose a standardized template for PM fetal and neonatal imaging referrals to enhance communication between referring clinicians and reporting radiologists.
METHODS: A modified Delphi approach was conducted amongst members of the European Society of Paediatric Radiology (ESPR) PM Task Force and other recommended PM imaging specialists worldwide to determine consensus on necessary information. These were based on three pre-existing referral templates already in use across a variety of centers. The study ran for 4 months (December 2023-April 2024).
RESULTS: Nineteen specialists from 17 centers worldwide formed our expert panel. The final agreed referral template information includes the patient\'s identification details (mother and fetus when available), fetal/neonatal information (gestational age, sex, type of demise (including type of termination of pregnancy (i.e., surgical or medical)), date and time of fetal demise (+ delivery) or neonatal death, singleton/multiple pregnancy, clinical information (obstetrical history, prenatal imaging findings, amniocentesis findings, physical external examination findings), provisional clinical diagnosis, and ordering physician\'s information.
CONCLUSIONS: A comprehensive referral template has been created, representing expert consensus on the minimum data required for the conduct of quality PM fetal and neonatal imaging, with the goal of facilitating accuracy of image interpretation.

UNASSIGNED: Fetal death has various causes, among the most common are problems relating to the placenta, such as placental abruption or placental malformations such as placenta accreta. From the literature, it emerges that placental analysis at autopsy can allow for greater resolution of cases compared to clinical history and external examination of the fetus alone.
UNASSIGNED: We report the case of a woman at the eleventh week of pregnancy who died in hospital. The medical history revealed two further previous pregnancies, both with births by cesarean section. The autopsy identified the cause of maternal death as acute cardiorespiratory arrest secondary to hemorrhagic shock from spontaneous uterine rupture. Hemorrhagic infiltrate was found in the intervillous placental spaces with rupture of the uterus due to placenta previa and accreta.
UNASSIGNED: Placenta accreta is a condition in which a pathological adherence and/or invasion of the myometrium by the placenta is observed. This condition poses a problem during recovery with potential for severe bleeding. Therefore, we emphasize the macroscopic and histological analysis of the placenta, uterus and the ovaries in all cases of maternal-fetal death, suggesting however that the organs be analyzed both by gross analysis and after permanence in formaldehyde. Furthermore, in these cases, it is important to evaluate the clinical history and data, especially ultrasound scans performed in life, or insertion anomalies during instrumental investigations. For this reason, we recommend to collaborate with a multidisciplinary team in these cases, including the gynecologist and the forensic pathologist.

BACKGROUND One of the obstetric complications of twin pregnancy was the intrauterine death of one fetus. The death that occurs in the first trimester usually leads to fewer complications than the death in the second and third trimester. In the second and third trimesters, single fetal death of twin pregnancy was reported to increase the death, preterm birth, and neurological injury of the surviving co-twin. Although rare, it might trigger a coagulation defect in the mother as well. Neurological morbidities were also more common in monochorionic twins than in dichorionic gestation. Thus, a consideration of pregnancy termination might persist. CASE REPORT We present a case of a primigravida with a monochorionic twin pregnancy whose intrauterine death of one fetus at 20-21 weeks of gestation. We managed this patient with pregnancy continuation under close monitoring more than 12 weeks until she delivered the surviving one at term. The outcome of the surviving baby was normal condition and appropriate weight, no fetal morbidity, and no maternal morbidity related to coagulation disorder in the mother. CONCLUSIONS Conservative management under close monitoring until term in monochorionic twin pregnancy with single fetal death could be the best option to obtain a favorable outcome. We recommend conservative management with close surveillance monitoring using non-stress tests after 32 weeks, biweekly ultrasound, and at least of one maternal coagulation profile test.